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HomeMy WebLinkAbout967872Recording requested by when recorded mail this deed to: Patricia M.A. Wasielewski 3473 Gibson Avenue Santa Clara, CA 95051 Mail Tax Statements to: Same as above APN# RECEIVED 11/9/2012 at 10:05 AM RECEIVING 967872 BOOK: 797 PAGE: 785 JEANNE WAGNER LINCOLN COUNTY CLERK, KEMMERER, WY AFFIDAVIT DEATH OF TRUSTEE Patricia M.A. Wasielewski, of legal age being first duly sworn, deposes and says that: Stanley Wasielewski and Patricia M.A. Wasielewski, naming themselves as trustees on May 31, 1995, established a revocable living trust titled: Wasielewski Family Trust created on May 31, 1995 Concurrent with the establishment of the living trust, Stanley Wasielewski Patricia M.A. Wasielewski executed a notarized deed formally validly transferring ownership interest of the real property to the above named living trust. Said deed was recorded on July 17, 1995 as Document #805207, Book #370PR, page 835. Said property is described as follows: Lincoln County, State of Wyoming SE1 /4 NW1 /4 of Section 11, Township 34 North, Range 119 West of the Sixth P.M., Lincoln County, Wyoming, together with all water and water rights, ditches and ditch rights, improvements and appurtenances thereon. Unfortunately, due to death (verified by the attached copy of the death certificate the decedent being Stanley Wasielewski), the duty for managing the trust now falls to Patricia M.A. Wasielewski, the successor trustee who now has rightful signature power for transferring or encumbering all the property owned by the trust including said real property. SUCCESSOR TRUSTEE STATEMENT This is to verify that I am the named and rightful successor trustee of the above referenced trust, and that all the statements and exhibits are true and correct. Dated: November 5, 2012 Signed: State of California County of Santa Clara BARBARA ROBINSON GOMM. 1857332 /11 '0" W NOTARY PUBLIC CALIFORNIA of WI aA COUNTY Of SANTA lMAnn Patricia M.A. Wasielewski Subscribed and sworn to (or affirmed) before me on this 5th day of November, 2012, by Patricia M.A. Wasielewski, proved to me on the basis of satisfactory evidence to be the person(s) who appeared before me. Mail Tax Statements as Directed Above Ctil NOTARY PUB IC CERTIFICATI ITAL RECORD 1, NAME OF (DECEDENT FIRST (GNen1 STANLEY''' AKA, ALSO KNOWNAS;- Indira. lire AKA (FIRST, MIDOLE,LAST) B. BIRTH STATE/FOREIGN COUNTRY NJ 13. EDUCATION. Ogees LeN0Dee,.s Nee worksheet en back) PROFESSIONAL 17. USUAL OCCUPATION Type Omura :or most or Rfe. 00 NOT USE RETIRED ENGINEER 20. DECEDENT'S RESIDENCE (Street and number, Or Idcallon) 3473 GIBSON AVE 10. SOCIAL SECURITY NUMBER WAS OECEOENINISPANICAATINO9VSPANISH7 01)... ire oolWael m beeN NO 12. MARITAL STATUS/SROP' St 11m. el'O.i.4 MARRIED 16. DECEDENT'S RACE Up to 3 races may be gated )a;e.4 okaM.l on b ck) WHITE 19, KINO OF BUSINESS OR INDUSTRY (e.g.. grocery EROSPACE store, road cen0 JclIon, employm.nl agency. etc.) A 7. GATE OF DEATH nVeryeryy 10/21 /2012 18 YEARS IN OCCUPATION 35.. 26 CITY 22. COUNTY/PROVINCE 23. 21P CODE 26 YEARS IN COUNTY 25. STATE/FOflE1GN'COUNTg SANTA CLARA' SANTA CLARA 95051 6648 56 CA 26 INFORMANTS NAME. RELATIONSHIP PATRICIA WASIELEWSKI WIPE I 34BSON A 27, 73;GIINFORMANT'S M/JUNG ADDRESVE, SAA CLARA CA S (Sl eel and NT number Or ru,a1 ro0N nlanber J0) g051 -6648 I'aWn .tal. and zip) 201 NAME OF SURVIVING S'POUS -FIRST 29. M1001.2 00, LAST (010TH NAME) PATRICIA MARIE ANN EAU. SHER FATHER/PARENT-FIRST 31. NAME OF FATHER/PARENT-FIRST 02: MIPOLE 33. LAST 34. 611710 STATE STANISLAUS WASIELEWSKI. SR WV 35. NAME OF MOTHER/PAREM' -FIRST 36 AS MIDDLE 21. LT (BIRTH NAME) 36, BIR1:H STATE STEPHANIA ROSE SABAT POLAND 10/29/2012 61. 11176020 ISPOSRION(Si 62. SIGNATURE OF EMBALMER 43..UCENSE NUMBER: CR /RES NOT EMBALMED,. NAME OF FUNERAL ESTABLISHMENT 05. UCENBE NUMBER' 08. SIGNATURE OF LOCAL REGISTRAR OT O TE lttdd/nnyy N EPTUNE..SOCIETY OF CENTRAL 1,0/24/2012 CALIFORNIA' FD1322 f. MARTIN' D FENSTERSHEIf9, MD (O+, PLACE OF 06014 102. IF HOSPITAL, SPECIFY ONE 1 03. IF'OTHER THAN HOSPITAL 5PEOFY ONE IP Hlace Nua nO Oe KAISER :FOUNDATION HOSPITAL -SANTA CLARA E1'° OOA m HNnee. TD ®Hpmcedene l Other 104:O.OUNT? 105. FACILITY A00RE5SOR.LOCATION WHERE'FOUNO (509.1 and b number, or ca0gn 106. pre, SANTA CLARA 700 LAWRENCE EXPRESSWAY' SANTA CLARA 107. CAUSE OF DEATH E3I., IN chain 4) .9671 dMel09 injWMt rnmpinik that NreclN0.7 00 NOT enter I.miES.7.MS such Rm)k))eNde1 e8 1860FATHREPOIl1E0T0(ARONERT cardiac areal: 1. es.07 4 0)1 9606 9n8 M 00nWKSWng'JNe Widow. 057 00NOTABBREYIATE: 060.1 1160 ab IMMEDIATE CAUSE IA) CARDIAC ARREST �I anb rss.ning IMM.ED': 12 03706' 4 171 tlaeNl' (BI PULSELE.SS ELECTRICAL ACTIVITY �n:: BIOPSY P06FGRMED1 S.n t 700 HRS YES' ©NO ii conditions, If eery, leading to yaw., Lk"- E7ter; CORONARY ARTERY. DISEASE (On 710. AUTOPSY PERFORMED? UNDERLYING CAUSE (dlaanaebr YRS El yes 710 Injury NaL� Initiated the .yenta 0 resulting In 48.UO LAST 111 USEOIN DETE CA05 resulting YES 0 +12. OTHER SIGNIFICANT CONDITIONS CONTRIBUTING TO DEATH BUT NOT RESULTING IN THE UNDERLYING CAUSE GIVEN IN 107 CONGESTIVE HEART' FAILURE, ATRIAL FIBRILLATION 113, WAS OPERATION 07ER2ORMSD FOR AN Y C6 ITEM 101 OR 112? (It yes. Ibl•Npe of operation and data) 113A IF FEMALE, PREGNMIrS u5SrY5ART NO YES 1111 NO ■UNK ,16:11100 MT 1FV1TTdmE BESTOFMY KNOWLEDGE 0FAM OCCURRED 115. SIGNATURE AND rrn.K OF CERTIFIER 110.130650E NUMBER 117 OATS mMdd /ecyy AT IHE 01000. OAIE, WORLACESTATEO FROM THE CAUSES STATED. o .d.nlAttended sl«. o:e.denl IswnA;v: HARPREET SINGH. PANNU M D A:103557 10/24/2012 (A) mM414)04 y (8) mMdd/ccyy 11S.TYF'E'ATTENOINGPMYSIOI WSO AE,MNUNGA00RESS,2+PC00E SINGH PANNU Mb. I 09/24/2012 10/20/2012 710 LAWRENCEEXPRESSWAY,.SANTA CLARA, CA:95051. 1& 1 I CEfRIFYTHAT MYOPIMON (1,EM1M PR OCCUED AT THE N9UR, DATE, ANO PUCE STATED FROM THE CAUSES STATED. 120. INJURED AT WORKT 121.IN1URY DATE. nlmldd /ceyy 122. NOVA (26 Noun( MANNER OF'.OE7214 N.IV(il�' ■'HOIn11W 51111,). n IW, Ill dNnmkKKied YES IIII, NO IN UNK 123. PUCE OF INJURY (.,o., (IOM Oonst,UCllon ells, wooded area. ele.) 534,050046 OCCURRED (Events welch .0)1.41. M)ury) 125. LOCATION OF INJURY (Slot and number, w 64.11071, and city, and zip) 126. SIGNATURE OF U[l',C CORONER:( OEpORONEO. 127. OATS mnVdd/ccyy 126. TYPE NAME, TITLE OF CORONER 7 €PUT? CORONER STATE R IIIIIIIIIIII11111111111IIIHIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII FAXAUTH.R (I CENSUS TRACT EGISTRAR; '.01000100t1831.2.2* STATE FIDE NUMB CERTIFIED COPY OF VITAL RECORDS u III I N�III III II STATE OF CALIFORNIA OCT .2x:201 II IIII VIII III DALE, ISSUED COUNTY OF SANTA CLARA SS B y I '2 8 0 Q: r„ 4 2 This is a true and exact reproduction of the document officially registered and placed on file in the VITAL RECORDS SECTION, DEPARTMENT OF PUBLIC HEALTH. MARTIN D. FENSTERSHEIB' HEALTH OFFICER AND LOCAL REGISTRAR OF BIRTHS AND DEATHS prepared on engraved border displaying seal and signature of Registrar. e OF FINAL OISPO$ mON RES'OF'PATRICIA.WASIELEWSKI 34.73 GIBSON`AVE, SANTA CA 95051 `TbiS :Copy not valid'pniess PBNCDIRET06/. PUBLIC HEALTH DEPARTMENT VITAL RECORDS AND REGISTRATION CERTIFICATE OF DEATH STATEOFCAUFORNR USE SLACK WK ONLY NO ERASURES WHITEOUTS OR ALTERATIONS I'3- 114REY 1/06) LOCAL REGISTRATION NUMBER